Client Registration Form

Your name

First Name Last Name

Current Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Your Email Address

example@example.com

Your phone number

Please enter a valid phone number.

Do you have a secondary phone number? (Different from secondary contact)

Please enter a valid phone number.

Is there another person you would like listed on your account?

First Name Last Name

Secondary Contact's Phone Number

Please enter a valid phone number.

Secondary Contact's Email Address

example@example.com

Preferred contact method

Phone Call Email Text Message

Pet's Name

First Name Last Name

Pet Species/Breed (EX: Dog, Labrador Retriever)

Pet Color

Pet's Birthdate

Date

Is your pet spayed/neutered?

She is spayed He is neutered My pet is unaltered (intact)

How did you hear about us? Did a friend refer you? If so, list there name below.

*If you are registering as a new client for an Avian, Small "Pocket Pet", or Reptile, please also fill out the corresponding questionnaire*

Is your pet microchipped?

Yes No

If known, please list the microchip number here

Previous Animal Hospitals name and phone number

If you have copies/photos of your pets medical records, please upload them below. If the file is too large, please contact the front desk and we can supply you with an email to send them instead.

Let's see how cute your pet is!

I _____ South Wilton Veterinary Group to take, and post photos of my pet on social media for educational and entertainment purposes.

Authorize Do not authorize

Signature

Clear

Date Signed

Date

Payment: Please understand that payment is expected at the time services are rendered, or upon your pet's discharge from the hospital. In the event of an open balance, you understand that your outstanding balance will incur a monthly finance fee equal to 8% per annum, the maximum interest fee allowable by the state of Connecticut. A minimum deposit of one-half of the estimated cost is required upon admission.

We offer and accept Care Credit, which is a credit card that can be used at most veterinary hospitals. You can apply right at our front desk, and find out in about 5 minutes if you are approved. If approved, in most cases, you can use your Care Credit immediately for both routine and emergency veterinary care.

Medical Records Privacy Policy: South Wilton Veterinary Group maintains a privacy policy regarding our patient's medical records. We only release records to the person listed as the owner of the pet on our paperwork. If medical records are requested by an outside party such as a kennel, groomer, new owner, or someone of unknown relation, we will need to get approval from the listed owner, prior to releasing any detailed information.

I agree to the terms and conditions stated in this document. I am the authorized party who will be responsible for making medical decisions, and providing payment for all services pertaining to the pet(s) on my account

Clear

Date Signed

Date